Reflux symptoms – functional and structural diseases The approach from the general practitioner (GP)

A primary care management strategy of gastroesophageal reflux disease (GERD) should pay attention to the epidemiology, prevalence and distribution of reflux-like symptoms in the community, to the special characteristics of patients presenting for the first time with reflux symptoms in primary care. General practitioners (GPs) encounter daily challenges to make cost-effective differential diagnostic and therapeutic decisions, avoiding needless and costly investigation or referral. They should provide long-term effective control of symptoms and esophageal healing in a personalized, symptom based, patient-centered and evidence-based manner. GPs should use a practical system of triage, in order to distinguish the high majority of patients with self-limiting conditions, from the minority with alarm symptoms with potentially severe disorder. They should also discriminate between troublesome and non-troublesome reflux symptoms. Most GERD is uncomplicated and can be treated using management algorithms that make the best use of resources. Some strategies such as “step-down”, “intermittent” or “on-demand” therapy can cost-effectively improve the long-term management and quality of life of patients with recurrent GERD. The accurate interpretation of “step-down” therapeutic strategy and a careful interpretation of proton pump inhibitor refractoriness are also essential.

Transgastric-Assisted Endoscopic Fundoplication

Gastroesophageal reflux disease (GERD) is a common entity in the United States. Surgical fundoplication can be performed safely with well-established long-term results. In selected patients with GERD, endoluminal therapy has a potential role. We report on a patient with recurrent GERD after two prior fundoplications who wished to pursue endoscopic treatment. The presence of a gastrostomy tube allowed for the performance of a transgastric-assisted endoluminal fundoplication using the EndoCinch (TM) device and standard pediatric laparoscopic instruments. Symptomatic relief of GERD with EndoCinch (TM) is common but the long-term outcomes are limited. Nevertheless, the EndoCinch (TM) device remains a method for endoscopic suturing in certain settings. In patients with gastrostomy access, the use of laparoscopic instruments may further enable the performance of advanced endoscopic therapies.